changes in two children with cerebral palsy after …...changes in two children with cerebral palsy...

C A S E R E P O R T

Changes in Two Children withCerebral Palsy After Intensive SuitTherapy: A Case ReportAmy F. Bailes, PT, MS, PCS, Kelly Greve, MPT, PCS, and Laura C. Schmitt, MPT, PhD

Division of Occupational Therapy and Physical Therapy (A.F.B., L.C.S.), Cincinnati Children’s Hospital Medical Center,Cincinnati, Ohio; Independent Pediatric Physical Therapist (K.G.), Locust Valley, New York; and Sports MedicineBiodynamic Center (L.C.S.), University of Cincinnati College of Medicine, Cincinnati, Ohio

Purpose: The purpose of this case report was to investigate effects of intensive suit therapy on gait, functionalskills, caregiver assistance, and gross motor ability in children with cerebral palsy. Case Description: Twochildren with spastic diplegia classified at level III on the Gross Motor Function Classification System partici-pated. Outcomes were assessed using dimensions D and E of the Gross Motor Function Measure, the PediatricEvaluation of Disability Inventory, and instrumented gait analysis. Intervention: Each child participated in theTherasuit Method, 4 hours a day, 5 days a week for 3 weeks. Outcomes: Very small improvements in functionwere noted in dimension D of the Gross Motor Function Measure and Pediatric Evaluation of DisabilityInventory Self-care Domain with decreased function in other areas. Improved walking speed, cadence, sym-metry, joint motion, and posture were found with gait analysis. Conclusion: Further investigation is needed ofthe suit itself, and intensive therapy programs in children with cerebral palsy. (Pediatr Phys Ther 2010;22:76–85) Key words: activities of daily living, cerebral palsy, child, exercise intensity, exercise therapy, humanmovement system, motor skills, physical therapy modalities, self care, space suit, spastic gait

INTRODUCTION

“Cerebral palsy (CP) describes a group of disordersof the development of movement and posture, causingactivity limitation, that are attributed to nonprogressivedisturbances that occurred in the developing fetal orinfant brain.”1 Children with CP typically demonstrateproblems with body functions and structures, such asdecreased muscle strength, limited passive joint mobil-ity, altered motor control, and poor alignment that limit

their activity. Physical therapy (PT) interventions ad-dress these problems with the goals of improving move-ment patterns and optimizing the child’s ability toparticipate in functional activities such as gross motorskills and ambulation. The benefits of task-specifictraining2– 4 and muscle strengthening5–10 in children withCP are known; however, the appropriate intensity oftraining and strengthening, necessary to maximize thebenefits, is unknown and is a topic of interest to pediat-ric therapists.

The typical frequency of physical therapy for childrenwith CP in an outpatient setting is not well documented. Re-cently, attention has been given to the potential benefits ofinterventions that advocate intensive bursts of therapy. Forexample, strengthening programs with frequencies of up to 3times a week demonstrate improvements in gait and func-tion.5–10 Protocols have been center based5,9,10 or home/com-munity based6–8 and have reported changes in gross motorfunction,6,7,9,10 cadence, and walking speed.6,8,9 Other moreintensive programs, with a frequency of up to 5 times a week,suggest that functional and gross motor skills of children withCP are improved when rehabilitation focuses on training-specific functional skills (FS).3,4 One type of high-frequencyintervention program, intensive suit therapy, is becoming

0898-5669/110/2201-0076Pediatric Physical TherapyCopyright © 2010 Section on Pediatrics of the American PhysicalTherapy Association.

Address Correspondence to: Amy F. Bailes, PT, MS, PCS; CincinnatiChildren’s Hospital Medical Center, Division of Occupational Therapyand Physical Therapy, MLC 4007, 3333 Burnet Avenue, Cincinnati, OH45229. E-mail: [email protected] Support: Cincinnati Children’s Hospital Medical Center ResearchFoundation, Cincinnati Children’s Hospital Medical Center Patient CareInnovations Fund, and the Smiles for Kids Foundation.At the time of this study Ms Greve was with the Division of OccupationalTherapy and Physical Therapy, Cincinnati Children’s Hospital MedicalCenter, Cincinnati, Ohio.

DOI: 10.1097/PEP.0b013e3181cbf224

76 Bailes et al Pediatric Physical Therapy

available to patients and families at more locations through-out the United States and other countries.11 One such pro-gram, the Therasuit Method, is a 3-week program that com-bines strengthening and FS training with a frequency of 3 to 4hours a day, 5 days a week and claims to improve function ata faster rate than other therapy programs.11 Proponents saythat the Therasuit Method “aligns the body to as close tonormal as possible,” “promotes development of both fine andgross motor skills,” and “normalizes (corrects) gait pattern.”12

The Therasuit Method includes using the Universal ExerciseUnit (Fig. 1) and wearing a suit (Figs. 2A, B) with bungeecords attached in ways to “stabilize,” “facilitate,” and “load”muscle groups.13

Evidence indicating greater functional benefit fromparticipation in intensive suit therapy is limited. Theonly published study of intensive suit therapy is a pro-spective randomized quasi-experimental study compar-ing neurodevelopmental treatment with intensive suit

therapy in 24 children with CP (aged 6 –12 years, GrossMotor Function Classification System [GMFCS] levelsII-IV).14 Each group participated in a therapy program of2 hours a day, 5 days a week, for 4 weeks. Immediatelyafter and 10 months after the intervention, the functional out-comes were measured using the Gross Motor Function Mea-sure (GMFM)-66, and energy cost was calculated for stairclimbing. Both the neurodevelopmental treatment and inten-sive suit therapy groups showed improvement in motor skillsand energy efficiency compared with baseline, but between-group analyses showed no statistical difference. Interestingly,when each treatment group was further classified based onpreintervention motor function, the suit intervention resultedin increased mechanical efficiency at 10-month follow-up forthose with higher level motor function at baseline.

Although Bar-Haim et al14 did not find statisticallysignificant effects of suit therapy on motor function, pub-lished abstracts of suit therapy with weaker methodologydo suggest improvements in function as measured by theGMFM-88,15,16 walking ability,17 and performance on the6-minute walk test.16,17 Also, Dabrowski et al18 publishedan abstract in which they reported a randomized andblinded study comparing the function of a heterogeneousgroup of children with CP (n � 50) who completed anintense program while wearing a suit with that of a groupwho completed the same program without a suit. The au-thors18 suggested that those wearing the suit demonstratedgreater improvements in GMFM scores during a 12-weekfollow-up period, but the difference was not statisticallysignificant. However, this work by Dabrowski et al18 sug-gests that gait analysis may be a useful outcome measure todetermine effects of the suit in future work.

Although studies imply a trend toward improvementin function after intensive suit therapy, the effectiveness ofsuit therapy programs on gait and function has not beenestablished. Therefore, the purpose of this case report wasFig. 1. Universal exercise unit.

Fig. 2. A, Example of patient working in the universal exercise unit wearing the Therasuit. B, Gait training in the Therasuit.

Pediatric Physical Therapy Intensive Suit Therapy in CP 77

to investigate the effects of intensive suit therapy on gait,FS, caregiver assistance, and gross motor ability in 2 chil-dren with spastic diplegia.

DESCRIPTION OF CASES

Two children with spastic diplegia participated in in-tensive suit therapy per the Therasuit Method.19 This studywas approved by our institution’s Internal Review Board,child assent was not required, and consent was obtainedfrom each caregiver/guardian before the initiation of thestudy. A description of each child’s history is summarizedin Table 1. Both children had a medical diagnosis of spasticdiplegia, were classified as level III on the GMFCS, hadpreviously participated in the Therasuit Method, could fol-low instructions, and were not taking oral antispasticitymedication. Exclusion criteria were as follows: hip sublux-ation �35%, severe scoliosis, intrathecal baclofen pump,autism, attention deficit disorder, progressive encephalop-athy, any psychiatric or behavior disorders, or uncon-trolled seizures. Each child was cleared by a physician be-fore participation in the intervention.

MEASUREMENT TOOLS

Performance on the Pediatric Evaluation of DisabilityInventory (PEDI), dimensions D and E of the GMFM, and3-dimensional gait analysis were measured before and afterthe intervention. The preassessment was completed 3 daysand 10 days before the intervention for participant 1 and 2,respectively. For both participants, the postassessmentswere completed 4 days after the intervention. The samephysical therapists administered the PEDI and dimensionsD and E of the GMFM (A.F.B.) and the gait analysis(L.C.S.) before and after the intervention.

PEDI

The PEDI is a parental-report questionnaire that assessesthe functional abilities of infants and children aged 6 monthsto 71⁄2 years old. However, the PEDI can be used with olderchildren if their abilities are less than expected for a 71⁄2-yearold child without disabilities.20 The PEDI has 2 scales, FS andCaregiver Assistance (CA). Within each scale, there are 3 do-mains: self-care, mobility, and social function. In this study,the self-care and mobility domains within each scale were

used, as it was expected the intervention might change scoresin these areas. For the FS Scale, each item on the PEDI isscored as 0 (unable to perform) or 1 (able to perform), and atotal score is obtained by adding the items.20 For the CA Scale,the items are scored from 0 to 5 (0, total assistance to 5,completely independent). Scaled scores were used to evaluatechanges over time. The PEDI has established reliability,20 va-lidity,21,22 and has been shown to be sensitive to change inchildren with CP.23,24

Dimensions D and E of the GMFM

The GMFM is an assessment of motor skills developedfor children with CP that was originally developed as an 88-item instrument, and after Rasch analysis was reduced to 66items to improve interpretability.25 It has been shown to bereliable, valid, and responsive to change in gross motor func-tion for children with CP.25 Item scores range from 0 to 3 (0,does not initiate to 3, completes). The items on dimension D(standing) and E (walking, running, and jumping) are thesame for both the 88- and 66-item versions. However, dimen-sion percentage scores, as described in the manual for theGMFM-88, rather than a total test score from the GMFM-66or -88, can be used when detecting change over time in a specificarea of interest.25 Higher level skills were of most interest inthis case report; therefore, percentage scores on dimensions Dand E were evaluated, as has been done previously.26

Three-Dimensional Gait Analysis

Trunk, pelvis, and lower extremity joint motion dur-ing walking was tracked using a digital 10-camera motionanalysis system (Eagle cameras, Motion Analysis Corpora-tion, Santa Rosa, Calif) at 240 Hertz (Hz). The cameraswere set-up to detect the motion of reflective markers (10mm) secured bilaterally over the acromion process, ante-rior superior iliac spine, anterior aspects of the mid-thighand tibial tubercle, medial and lateral femoral condyles,medial and lateral ankle malleoli, the dorsal aspect of thefoot between the second and third metatarsals, base of thecalcaneous and over the sacrum and left scapula.

Participants walked barefoot along a 10-meter walk-way at their self-selected walking speed and were encour-aged to walk as independently as possible. Participant 1

TABLE 1Participant History

ParticipantGender Age* Diagnosis

Preferred Method ofCommunity Ambulation

Muscle Groups and AgeWhen Botox Was Injected

Procedure and Age When SurgeryWas Performed

F 8 yr, 3 mo CP, spastic diplegia Using 1 Lofstrand crutch B Gastrocnemius: 33 mo,60 mo; B Hamstrings:36 mo, 41 mo, 44 mo

Selective dorsal rhizotomy, 47 mo;percutaneous selective myofasciallengthenings of B hamstrings,Achilles tendons, and adductors, 82 mo

M 7 yr, 11 mo CP, spastic diplegia Using 2 single-point canes B Gastrocnemius: 29 mo,36 mo; B Hamstrings:33 mo

Selective dorsal rhizotomy, 36 mo;percutaneous selective myofasciallengthenings of B hamstrings, Achillestendons, and adductors, 72 mo

*At start of intervention.B indicates bilateral; CP, cerebral palsy.


completed both gait analyses without assistance and par-ticipant 2 used single-point canes bilaterally during bothgait analysis sessions. During walking, marker trajectorieswere recorded (EvaRT software, Motion Analysis Corpora-tion, Santa Rosa, Calif), and data collection continued untilat least 4 usable trials were collected for each lower extrem-ity. A usable trial was operationally defined as one in whichall markers were visible throughout the entire trial andconsecutive steps were taken by the participant along therecording length of the walkway. Data were collected in thesame fashion during the pre-testing and post-testing.

The data were processed using Visual 3D software (C-Motion, Inc. Rockville, Md). Marker data were filtered with afourth-order Butterworth filter at a cut-off frequency of 6 Hz,and joint angles were calculated with Cardan angles. Initialcontact and toe-off were defined using the heel marker andtarget pattern recognition. Lower extremity joint angles werenormalized to 100 data points across the gait cycle (initialcontact to ipsilateral initial contact) and trunk and pelvis mo-tion were normalized to 100 data points across stance phase(initial contact to ipsilateral toe off).

DESCRIPTION OF INTERVENTION

The Therasuit Method of intensive suit therapy was ad-ministered for 4 hours a day, 5 days a week for 3 consecutiveweeks by physical and occupational therapists specificallytrained in the intervention protocol. All of the activities of theTherasuit Method were administered in the same sequenceeach day (see Table 2 for details). The Therasuit was fit basedon each child’s size and was only worn during the treatmentintervention beginning with 30 minutes of wear time on day 1of the intervention. Each child then progressed to wearing theTherasuit an additional 30 minutes each day to a maximumwear time of 2.5 hours by day 5 of the intervention and for theremainder of the program. During treatment, both childrenwore the suit with bungee cords placed over the abdominals,

trunk extensors, obliques, gluteals, and the scapular region.Bungee cords were used to connect the vest to shorts, shorts tokneepads, and kneepads to shoes. Each participant’s specificprogram was individualized with the goal of advancing thepatient to the next level of function. Both participants com-pleted the program, and each family was instructed in a homeprogram to maintain functional gains at the end of the program.

The program for participant 1 focused on achieving 2functional goals: ambulating without Lofstrand crutchesfor community distances and greater independence in self-care skills. Additional bungee cords were added duringweeks 2 and 3 for hip stabilization and to facilitate kneeflexion and ankle plantar flexion. This child worked onsingle limb stance activities, ambulation without an assis-tive device on level and uneven surfaces, stairs, curbs,jumping jacks, dynamic balance skills, using utensils, anddressing skills (shoes, socks, orthoses, pants, and fasteningsmall buttons on shirts) throughout the 3 weeks.

The program for participant 2 focused on achieving 2functional goals: getting up from the floor and ambulatingwithout single-point canes for short distances. Additionalbungee cords were added for the duration of the programfor bilateral hip stabilization. This child worked on kneewalking, floor to stand transitions, stair climbing, dynamicbalance, ambulation with and without an assistive device,hamstring stretching, and typing throughout the 3 weeks.He presented with knee pain before beginning the pro-gram, but he was able to complete the full program.

Data Analysis

Score changes on the PEDI self-care and mobility do-mains and dimensions D and E of the GMFM were com-pared between pretesting and posttesting sessions. Walk-ing speed, cadence, limb support time, step length, andjoint motion of the hip, knee, ankle, trunk, and pelvis werecompared between pretesting and posttesting sessions.

TABLE 2Sequence and Description of Therasuit Method Activities

Activity Description Duration

Hot pack and massage Upper and lower limbs 30 min (hot packs placed for 12- to 15-min periods; 3–6min for each lower limb massage; 3 min for each upper

limb massage)Pulleys Using universal exercise unit for lower limb

strengthening and range of motion/stretching30–45 min; approximately 2–4 exercises for 30

repetitions eachRest break � Toileting 5–10 min

Donning suit Therasuit and bungees donned 15–20 minTherapeutic exercises Trunk and lower limb strengthening using

Swiss balls, bolsters, plinths, benches30–40 min; 3–6 exercises for 30 repetitions each

Rest break 5 minPulleys Using universal exercise unit for upper

limb strengthening20 min; approximately 2 exercises for 30 repetitions each

Sensorimotor activities Using universal exercise unit for jumpingor swinging

5 min

Fine motor skills Activities of daily living and progressionof fine motor tasks

30 min

Rest break 5 minBalance and coordination activities Using universal exercise unit 20–30 min; 1–3 exercises completedGross motor functional skills Standing, transitions, and progression of

ambulation skills20–30 min


DESCRIPTION OF OUTCOMES

Dimensions D and E of the GMFM and PEDI

Tables 3 and 4 show pre and post scores of dimensionsD and E of the GMFM and PEDI scores. Minor changeswere seen on dimensions D and E of the GMFM and thePEDI with the largest increase documented for participant1 on the PEDI FS self-care domain. Other smaller increasesin FS and CA self-care were documented for participant 2.In addition, both participants demonstrated small de-creases on some domains of the PEDI.

Gait Analysis

Tables 5 and 6 show changes in gait characteristics forboth participants. Participant 1 demonstrated improvedwalking speed (0.26 m/s increase), decreased double limbsupport time (6% decrease), and no appreciable change instride length (0.04 m increase). Increased cadence was alsonoted, with small or no changes observed in single limb sup-port time and step length. Joint motion during walking beforeand after intervention are shown in Figures 3–5. Most nota-ble, Figure 3 shows improved hip extension at terminal stancechanging from 3.3° of hip flexion on the right to 10.9° of hipextension after the intervention, and on the left changingfrom 2.6° of hip flexion to 12.3° of hip extension after theintervention. Also, improved symmetry was noted with pelvicrotation (Fig. 4) and lateral tilt (Fig. 5).

Participant 2 demonstrated improved walking speed(0.14 m/s increase), no change in double-limb supporttime, and no appreciable change in stride length (0.01 mincrease). Cadence and single-limb support time both in-creased with small or no changes observed in step length.Joint motion during walking before and after interventionare shown in Figures 6 to 8. Notable improvements in-cluded reduced knee hyperextension motion during mid-stance, on the right reducing from 7.4° of extension to 0.5°of extension, and on the left reducing from 11.3° of exten-sion to 2.7° of extension (Fig. 6). Lateral trunk motion(Fig. 8) showed greater symmetry with little change noted

TABLE 3Participant 1, Preintervention and Postintervention Performance on

GMFM (Raw Scores �%�) and PEDI (Raw Scores �Scaled Scores�)

Participant 1 Pre Post

GMFM dimension D 29/39 (74%) 30/39 (77%)Single-limb support (Item 57) 0 1Single-limb support (Item 58) 0 1Stands, picks up object from

floor (Item 64)3 2

GMFM dimension E 41/72 (57%) 40/72 (56%)Walks forward between parallel

lines (Item 73)2 1

Steps over stick (Item 75) 1 0Kicks ball (Item 78) 3 2Walks backward (Item 71) 2 3Jumps forward (Item 81) 0 1

PEDI functional skills self-care 58 (67.6) 64 (72.6)Uses a knife (Item 9) 0 1Brushes hair (Item 22) 0 1Puts on shirt, not including

fasteners (Item 42)0 1

Buttons and unbuttons (Item 47) 0 1Zips and unzips (Item 48) 0 1Ties shoe lace (Item 58) 0 1

PEDI functional skills mobility 55 (82.5) 55 (82.5)PEDI caregiver assistance self-care 26 (62.2) 24 (60.1)

Dressing upper body (Item D) 3 1PEDI caregiver assistance mobility 30 (72.7) 29 (70.5)

Chair/toilet transfers (Item A) 5 4Stairs (Item G) 5 4

Scores on items that changed are reported.

TABLE 4Participant 2, Preintervention and Postintervention Performance on

GMFM (Raw Scores �%�) and PEDI (Raw Scores �Scaled Scores�)


GMFM dimension D 23/39 (59%) 25/39 (64%)Single-limb support holding

large bench (Item 54)2 3

Single-limb support holdinglarge bench (Item 55)

2 3

GMFM dimension E 19/72 (26%) 19/72 (26%)PEDI functional skills self-care 65 (73.6) 66 (74.7)

Puts on unfastened shoes (Item 55) 0 1PEDI functional skills mobility 56 (85.2) 55 (82.5)

Walks down stairs: no difficulty(Item 59)

1 0

PEDI caregiver assistance self-care 28 (64.5) 31 (68.1)Dressing upper body (Item D) 1 5

PEDI caregiver assistance mobility 35 (100) 33 (82.5)Car transfers (Item B) 5 3

Scores on items that changed are reported.

TABLE 5Participant 1, Temporal-Spatial Gait Characteristics


Walking speed, m/s 1.16 1.36Double-limb support, % gait cycle 17 11Stride length, m 0.97 1.1Cadence; �M (SD)�, steps/min

Right 142 (9) 146 (12)Left 144 (10) 159 (10)

Single-limb support time, % gait cycleRight 41 42Left 43 47

Step length; �M (SD)�, mRight 0.46 (0.06) 0.49 (0.03)Left 0.50 (0.03) 0.59 (0.03)

TABLE 6Participant 2, Temporal-Spatial Gait Characteristics


Walking speed, m/s 0.82 0.96Double limb support, % gait cycle 17 17Stride length, m 0.99 1.0Cadence; �M (SD)�, steps/min

Right 103.7 (8.07) 106.7 (9.18)Left 103.6 (8.5) 110.6 (17.6)

Single limb support time, % gait cycleRight 42 45Left 35 40

Step length; �M (SD)�, mRight 0.51 (0.02) 0.52 (0.06)Left 0.49 (0.04) 0.54 (0.05)


at the pelvis (Fig. 7). The use of single-point canes during thetesting sessions likely influenced trunk and pelvic motion.

DISCUSSIONThe purpose of this case report was to investigate the

effects of intensive suit therapy on gait, FS, CA, and gross

motor ability in 2 children with spastic diplegia. Both par-ticipants showed minimal gains in some areas and declinein other areas of functional performance after the TherasuitMethod of intensive suit therapy as measured by dimen-sions D and E of the GMFM and the PEDI. Our findingsindicate that intensive suit therapy may contribute to some

Fig. 3. Participant 1: Hip, knee and ankle flexion, and extension motion across the gait cycle. Dashes indicate pretesting session, dotsindicate posttesting session. Hash marks indicate toe-off.

Fig. 4. Participant 1: Pelvis motion across stance phase (initial contact to toe off) during pretesting session (top) and posttesting session(bottom). Gray, left side; black, right side.


improvements in gait, but further investigation is necessarybefore recommending this program.

The change scores on dimensions D and E of theGMFM were not as large as expected. Motor development

curves, based on the GMFM-66, suggest that the motordevelopment of the participants in this case report mayhave previously reached the expected limit of their poten-tial.27 As such, dimensions D and E of the GMFM may not

Fig. 5. Participant 1: Trunk motion across stance phase (initial contact to toe off) during pretesting session (top) and posttesting session(bottom). Gray, left side; black, right side.

Fig. 6. Participant 2: Hip, knee and ankle flexion, and extension motion across the gait cycle. Dashes indicate pretesting session, dotsindicate posttesting session. Hash marks indicate toe-off.


have been the most sensitive measure by which to detectchanges in the gross motor abilities of our participants afterthe intervention. Additionally, our study obtained scoreson only dimensions D and E, which makes it difficult tocompare our results with previous work reporting im-provements based on total scores.14–16 Only one other pub-lished abstract has reported improvements in GMFM di-mension scores after an intensive suit therapy program17;however, the description of the subjects suggests that theywere not GMFCS level III as in this case report.

We expected to observe improvements on both theself-care and mobility domains of the PEDI, and only ob-served small positive changes in the self-care domain. Ourresults are consistent with the work of Stiller3 following anintensive therapy program that did not involve a suit. Al-though the PEDI provides useful information regardingtranslation of motor skills to functional ability the outcomerelies on caregiver response, which may be influenced by

their expectations and beliefs regarding the tested inter-vention. As such, Stiller3 suggests that families report onmore noticeable differences but do not comment on thesmaller changes. Caregiver expectations or the previousparticipation of the participants in the program may haveinfluenced the small changes that we noted.

A unique aspect of this case report was the use of3-dimensional gait analysis to quantify changes in gait per-formance and movement patterns during walking after anintensive training program. Significant associations be-tween muscle strengthening programs and improved gaitperformance, specifically faster gait velocity (up to 0.18m/sec change28) and increased cadence (6 and 8 step/min increase6,28) have been reported in children withCP.6,28 Both children in this case report demonstratedincreased self-selected gait velocity after the interven-tion program with magnitudes of improvements that aresimilar to those previously reported.6,28 Also consistent

Fig. 7. Participant 2: Pelvis motion across stance phase (initial contact to toe off) during pretesting session (top) and posttesting session(bottom). Gray, left side; black, right side.

Fig. 8. Participant 2: Trunk motion across stance phase (initial contact to toe off) during pretesting session (top) and posttesting session(bottom). Gray, left side; black, right side.


with previous studies, increased cadence seems to be themechanism responsible for faster walking speed.6,29 Ofthe few studies5,9 that have examined gait kinematic dataafter strengthening interventions, increases of 2° to 8° ofjoint motion have been documented for programs thatspecifically focus on muscles of the knee5 and ankle.9

The intervention program used in this case report didnot only focus on strengthening and was comparativelybroad in nature. The Therasuit Method emphasizes notonly selective muscle activation but also transition andfunctional activities that require the coordination of sev-eral body segments and joints. The notable changes inhip and knee motion for participants 1 and 2, respec-tively, may represent meaningful improvement. How-ever, the functional significance (such as improved en-ergy efficiency) of our measured changes requiresanalysis beyond the methodology of this case series.

Although we expected to see greater improvements infunction and gait patterns after the intervention, the find-ings of this case report suggest several areas related to in-tensive suit therapy that warrant further investigation. Theobserved changes in hip and knee motion, and pelvis andtrunk symmetry have the potential to translate into moreenergy efficient walking patterns. We speculate that im-proved energy expenditure during walking and other func-tional activities may be one of the most beneficial outcomesof intensive therapy programs; however, we did not in-clude measures of metabolic cost in this study, and it re-mains an important area for future work. Further delinea-tion of the benefits of intensive therapy with or without asuit would be beneficial. Finally, all intensive therapy pro-grams require commitment and compliance of the patientsand families. The 2 children and families in this case reportshowed high compliance with the program, and anecdotalcomments from previous work14 suggests parent satisfac-tion with intense therapy programs. However, further re-search is needed to determine whether there are certaincharacteristics of children and families that choose inten-sive programs over other modes of service delivery.

We acknowledge the case report design used in thisstudy limits the applicability of the results. Further, familiesthat have participated in intensive suit programs have re-ported that functional changes are not observed immediatelyafter the intervention, suggesting that a longitudinal fol-low-up would be useful. Both participants in this case reportcompleted the training program, although participant 2 re-ported knee pain before and throughout the intervention,which could have been a confounding factor in functionalgains. The use of more sensitive measures of motor functionand quality of movement may have provided useful informa-tion regarding the benefits of intensive suit therapy.

CONCLUSION

Both participants in this case report showed minimalgains in some areas and decline in other areas of functionalperformance after the Therasuit Method of intensive suittherapy as measured by dimensions D and E of the GMFM

and the PEDI. We noted small but potentially importantchanges in gait movement patterns after participation inthis intensive program. Further investigation with largersample sizes is needed to examine the different compo-nents of the Therasuit Method before conclusions can bedrawn as to the effectiveness of the program. Finally, thisprogram is available at a substantial cost, and the benefitsobtained may not be worth the investment.

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ERRATUMEffects of Music on Crying Behavior of Infants and Toddlers During PhysicalTherapy Intervention: Erratum

In the article cited above, on page 329 of the Winter 2009 issue of PediatricPhysical Therapy, the caption of Fig. 1 included a grammatical error; thewords “those in” should have been deleted. The figure with the correctedcaption appears below.

Reference:

Rahlin M, Stefani J. Effects of music on crying behavior of infants and toddlersduring physical therapy intervention. Pediatr Phys Ther. 2009;21(4):325–335.

Fig. 1. Celeration lines for crying times across 3 periods of the study constructed forparticipant 1 (A), participant 2 (B and C), participant 8 (D), and participant 9 (E), whocried less in the music period compared with the first baseline period and subse-quently cried more in the second baseline period.

Pediatric Physical Therapy 85

changes in two children with cerebral palsy after …...changes in two children with cerebral palsy...

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